How Spravato and Ketamine-Assisted Psychotherapy Work Together
This article is the first of a two-part series examining how Spravato® and ketamine-assisted psychotherapy (KAP) complement each other in the treatment of depression. Read the companion article: When Insight Isn’t Enough: How Ketamine-Assisted Psychotherapy Helps Patients Heal From Trauma.
Severe depression takes away joy, identity, connection with others, and any sense of progress in life. Many people living with treatment-resistant depression (TRD) find they are enduring life rather than participating in it.
I have worked with patients who have spent 10, 15, even more than 20 years trying different antidepressants. The medications may help them function — they manage to get to work, pay bills, attend family events — but inside, they feel exhausted and emotionally absent. This long-term survival mode can profoundly affect marriages, parenting, friendships, and self-esteem.
Ketamine treatment creates a window for change
When we begin treating them with Spravato®, a nasal spray based on the ketamine derivative esketamine, something often begins to shift. Unlike traditional antidepressants, esketamine works through different neurobiological mechanisms that promote neural plasticity and cognitive flexibility.
Simply stated, the brain becomes more open to change. Research suggests this creates a temporary “window” in which psychotherapy can take a deeper root. Combining ketamine treatment with ketamine-assisted psychotherapy may enhance and sustain the beneficial treatment effects, as the same study finds. In my experience with patients, this is absolutely the case.
We often see the first signs of relief within days of beginning treatment. But after years, even decades, of emotional numbness, many patients find themselves asking: Now what? This is where ketamine-assisted psychotherapy comes in.
A man living with 15 years of severe depression
In my work, I often see a pattern like in the following story, which is a composite drawn from many patients: Imagine someone who’s lived with treatment-resistant depression for over 15 years and has tried every antidepressant available.
The medications help him drag himself through each day. At work, he does enough to get by, then closes his office door and rests his head on his desk between meetings. He stays in his office because he doesn’t have the energy to chat with colleagues.
Pushing down a granola bite for lunch is an effort. He feels the sensation of hunger but has no appetite. After work, he comes home and forces a weak smile to his wife and young daughter before heading straight to bed. His wife has gotten used to doing everything at home, from household chores to childcare.
On Sundays, his daughter asks for “daddy time.” He takes her to the park out of guilt, but every step feels like climbing a mountain. All he wants is to get back home and get into bed.
This all changes with Spravato. After a couple of sessions, he feels lighter. Small things begin to improve. At work, he notices that the food his colleagues bring smells good, and for the first time in years, he wants to try it. Two weeks after starting Spravato, he eats a full deli sandwich and can’t believe how good it tastes.
When a colleague knocks on his door during his break, he is able to smile and engage in small talk without it feeling like a huge exertion. Then he comes home from work and sits at the table with his wife and daughter for dinner. They can’t believe it.
Yet unexpectedly, the improvement also makes him feel overwhelmed. For years, he has been in survival mode. While he now feels relief from his depression, he doesn’t know what to do first, how to re-enter the life he’s been absent from, and how to repair the relationships that have adapted to his emotional distance.
Rebuilding connection after years of absence
Ketamine-assisted psychotherapy (KAP) helps him contain his feelings and figure out which part of his life he wants to address first. As his depression lifts, his first priority is being there emotionally for his daughter and wife. But how does he do that?
With the help of KAP, he finds the language to explain to his daughter what it meant that daddy was depressed, and what it means that he is getting better. He talks through how to reconnect with his wife.
When symptoms improve, patients often become aware of the patterns they’ve cemented around the burden they’ve carried. The patient has to relearn how to show up emotionally, how to communicate openly, and how to rebuild trust with his loved ones. The medication has energized him, and ketamine-assisted psychotherapy is helping him find his way forward.
From symptom relief to long-term recovery
Ketamine treatment may open the door. Therapy helps patients walk through it. In my work, I integrate cognitive behavioral therapy (CBT) and internal family systems (IFS).
Without additional support, the benefits of ketamine treatment may be short-lived, according to a clinical study. In the study, those receiving intravenous ketamine treatment who engaged in concurrent cognitive behavioral therapy (CBT) had lower relapse rates. In another study, patients who received ketamine infusions alongside psychotherapy showed more pronounced symptom reduction than those who received infusions alone.
CBT helps patients examine long-standing thought patterns, such as “I’m a burden,” “I’ve wasted my life,” “It’s too late to change”. It helps reframe those beliefs while building concrete behavioral changes. IFS helps individuals understand and integrate parts of themselves shaped by trauma, shame, or self-criticism.
The neuroplastic window created by Spravato presents an opportunity, but it can feel disorienting. In that space, ketamine-assisted psychotherapy helps to reflect deep insights gained in ketamine sessions and integrate them into daily life, creating lightness, connection, a sense of fulfillment and calm, and even joy.
If you’re struggling with treatment-resistant depression, Spravato and ketamine-assisted psychotherapy may offer a new path forward. Schedule a free consultation with a clinician at Keta Medical Center to explore whether this approach is right for you.
